Please complete the following registration form. All information will be kept confidential. You will be contacted after receiving and reviewing your application.

Note: Fields marked with an asterisk (*) are required.

Personal Information

First Name: *

Last Name: *

Address:

City, State, Zip:

Home Phone:

Daytime Phone:

Email Address:

Date of Birth:

Sex:

Marital Status:

Race:

Dominant Side:

Height:

Weight:

Tell Us A Little About Yourself

Background (school, hobbies, career objectives)

Your goals/objectives while at The Fitness Principle: *

How much time are you willing to commit to achieve your goals/objectives? *

On a scale of 1-10 (1 being not committed and 10 being very committed), how committed are you to obtaining your goals/objectives and abiding by the program guidelines?

1
2
3
4
5
6
7
8
9
10

How did you hear about The Fitness Principle?

EJGH.org

Current Client

Advertising

Other

Please answer the following questions by selecting the appropriate response. Use the space below to explain any "Yes" answers to the following questions. Have or do you:

01.

Have a history of medical problem or injury since your evaluation?

Yes
No

02.

Ever not been allowed to participate in exercise for a medical reason?

Yes
No

03.

Ever been hospitalized?

Yes
No

04.

Ever had surgery?

Yes
No

05.

Presently take any medication?

Yes
No

06.

Have any allergies to medicine or foods?

Yes
No

07.

Passed out during or after exercise?

Yes
No

08.

Been dizzy during or after exercise?

Yes
No

09.

Have chest pain during or after exercise?

Yes
No

10.

Tire more quickly than your friends during exercise?

Yes
No

11.

Have high blood pressure?

Yes
No

12.

Been told you have a heart murmur?

Yes
No

13.

Have racing of the heart or skipped heartbeats?

Yes
No

14.

Have a family member that died of heart problems or sudden death before age 50?

Yes
No

15.

Have any skin problems?

Yes
No

16.

Ever had a head or neck injury?

Yes
No

17.

Ever had a seizure?

Yes
No

18.

Ever had a stinger, burner, or pinched nerve?

Yes
No

19.

Have trouble with breathing or coughing during or after activity?

Yes
No

20.

Have any problems with vision?

Yes
No

21.

Ever sprained/strained, dislocated, fractured, or had repeated swelling for any bones or joints?

Yes
No

22.

Have any medical problems listed below?
If Yes, please check all that apply:

Yes
No

High Blood Pressure

Hepatitis

Asthma

Rheumatic Fever

Abnormal Bleeding

Mononucleosis

Diabetes

Tuberculosis

Other (List)

Please explain all YES answers from the questions above:

Health History

Primary Care Physician:

Physician's Address:

Physician's City, State, Zip:

Physician's Phone Number:

Work and Insurance Information (To be completed by applicant)

Employer:

Work Phone:

Policy #:

Health Behavior

01.

Do you sometimes feel that if you could only lose weight, you would then be able to achieve most or all of your other goals?

Yes
No

02.

Are you frequently depressed or anxious because of your weight?

Yes
No

03.

Do you feel "good" or "bad" according to how much you eat, how much you weigh, or how much exercise you get in?

Yes
No

04.

Do you frequently eat beyond the point of fullness, to the point of physical discomfort?

Yes
No

05.

Do you avoid eating for long periods of time as a way to control your weight?

Yes
No

06.

Do you feel compelled to eat when you are home alone?

Yes
No

07.

Do your eating and weight loss activities interfere with work, school and/or relationships?

Yes
No

08.

Do you get angry at people if they question what or how much you eat?

Yes
No

09.

Do you find you cannot stop thinking about food and/or weight?

Yes
No

10.

Do you eat when you are stressed, angry or sad?

Yes
No

You must answer all questions below in order to be considered:

01.

The above information is current and correct to the best of my knowledge.

Yes
No

02.

If in the judgment of a representative of the Program, I need care or treatment as a result of an injury or sickness, I do hereby request, consent to and authorize such care as may be deemed necessary.

Yes
No

03.

I recognize the evaluation to be done is a standard pre-participation screening examination, and that no in-depth testing, x-rays, lab work, or cardiac test work will be performed.

Yes
No

Waiver

Review the Waiver of LiabilityIn consideration of gaining membership and being allowed to participate in the activities and programs of the East Jefferson General Hospital Wellness Center (the “Facility”) and to use its facilities, equipment, and machinery, in addition to the payment of any fee or charge, I do hereby agree to the following:

1. I covenant not to sue and hereby forever release, waive and discharge the Wellness Center of East Jefferson General Hospital, its owners, directors, officers, operators, employees, a agents, representatives, members and guests (hereinafter referred to as “Releasee”) from any and all responsibility or liability for bodily injury, death or property damage resulting from my participation in any activity or my use of any equipment or machinery while I am in, upon, or about the premises of the Facility, including, without limitation, the locker room, restroom, parking area and sidewalk area. I further hereby agree to indemnify, save and hold harmless each and every Releasee from any loss, liability, damage or cost he/she may incur due to my presence or participation in any activity or my use of any equipment or machinery while I am in, upon, or about the Facility or participating in any program affiliated with the Facility.
Yes

2. This waiver and release of liability includes, without limitation, all bodily injuries and property damage which may occur regardless of Releasee’s negligence, as a result of: my use of any amenity or equipment in the Facility and my participation in any activity, class, program, personal training or instruction; the malfunctioning of any equipment; the instruction, training, supervision, or dietary recommendations made to me by any Releasee; and my slipping and/or falling while I am in, upon, or about the Facility, including, without limitation, the locker room, restroom, parking areas and adjacent sidewalks.
Yes

3. I understand and am aware that strength, flexibility, and various activities and exercise, including the use of equipment, are potentially hazardous. I also understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these activities and will use the equipment and machinery properly and with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of bodily injury, death or property damage that may result.
Yes

4. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities and programs of the Facility or use of its equipment or machinery. I do hereby acknowledge that I have been informed and am aware of the recommendation to have a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended to me that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise and training equipment so that I might have his/her recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given my physician's permission to participate, or that I have decided to participate in activity and/or use the Facility’s equipment and machinery without the approval of my physician and do hereby assume all risk and responsibility for said participation and use of equipment and machinery in these activities.
Yes

5. I acknowledge the Facility operates under rules and regulations established for the safety, comfort and protection of its members and other patrons and I will abide by and be bound by the Membership Information Handbook and all posted rules and regulations, as well as by rules and regulations subsequently approved and posted or published. The Membership Information Handbook and the Facility’s rules and regulations, in effect from time-to-time, are incorporated into this Agreement by reference and are made a part hereof. Breach of any rule or regulation will result in revocation of membership. Further, the Facility reserves the right to determine appropriate behavior in the Facility and reserves the right to restrict or deny access to the Facility to anyone or anything and/or cancel membership in its sole discretion.
Yes

The Waiver of Liability should be reviewed by the applicant or by the applicant's legal guardian if applicant is under 18 years of age, as well as by the applicant's physician were indicated below.

(“Participant”) acknowledges that he/she will be taking part in a program of exercise and athletic training including but not limited to activities of the Fitness Principle and/or The EJGH Wellness Center. It is acknowledged that medical clearance has been obtained specifically for such activities.

The undersigned desires to voluntarily utilize the services and, if applicable, facilities and equipment provided by The Fitness Principle and/or The Wellness Center for the purpose of personal fitness, recreation, or fitness evaluation. As a consideration for the right and privilege of being permitted access to, and the use of, services or programs offered by The Fitness Principle and/or The Wellness Center, and if applicable, facilities and equipment, the undersigned does hereby release The Fitness Principle, EJGH Wellness Center, East Jefferson General Hospital, its officers, agents and employees from any and all liabilities of any kind whatsoever arising out of any physical or mental injury incurred or sustained by the undersigned while at or participating in any of the fitness programs, recreational or evaluation services and facilities and use of equipment provided by The Fitness Principle and/or The Wellness Center; and furthermore, agrees to save and hold harmless The Fitness Principle, EJGH’s Wellness Center, East Jefferson General Hospital, its officers, employees, assigns, rising out of the undersigned’s use of the facilities and/or services.

Furthermore, the undersigned acknowledges that he or she may participate in activities involving physical exertion or exposure to heat or steam. The undersigned acknowledges that he or she has obtained independent medical approval to use the services or programs, and if applicable, facilities and equipment provided by The Fitness Principle and/or The Wellness Center for the undersigned’s participation in activities involving physical exertion and that he has made the Fitness Principle Director aware of any limitations suggested by his/her physicians.

The undersigned acknowledges and affirms that he or she has carefully read this release and has asked and obtained a satisfactory explanation of any part that he or she does not understand.

Yes, I Agree *

Medical Clearance

01.

Do you have a primary care physician?

Yes
No

If yes, is your primary care physician at East Jefferson General Hospital?

Yes
No

Name of Provider:

02.

Have you had a physical from a health care provider within the past 12 months?

Yes
No

03.

Have you had blood work from a heath care provider within the past 12 months?

Yes
No

04.

Would you like East Jefferson General Hospital to provide your medical clearance to enter into The Fitness Principle at East Jefferson General Hospital?

Yes
No

If no, please supply the name of the name of the provider that will provide medical clearance:

Name of Provider:

I understand that there may be diagnostic tests performed that may not be covered by insurance and that I will be responsible for those tests. I understand that if I have had a physical by my health care provider for medical clearance at this time, I will be personally responsible for any services not covered by my insurance.